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Wednesday, December 29, 2010

Here's just one example of why American health care costs so much more than anybody else's.

My husband is going to have outpatient hernia surgery in a couple of weeks. His doctor told him he had to get an EKG before surgery. He suggested that he go to the local urgent care facility to have it done. Being consumer-oriented types, we decided it would be a good idea to find out how much it was going to cost.

First, David called the urgent care center. They were sorry, but the billing office was closed. Could he call back the next day.

No problem. This morning he called the billing office. They were sorry, but they didn't know how much it would cost. He would have to contact his insurance company.

So he called Blue Cross Blue Shield Illinois. The EKG, they told him, would be billed as an outpatient procedure. There would be no co-pay, and since he had already paid his deductible, he would be responsible for only 20% of the cost. Right, said my husband, but how much will the cost be? They were sorry, they said, but they didn't know. That would depend on the provider's tax ID number and the diagnosis code.

So David called the urgent care center again. They gave him the provider's tax ID number and told him there was no diagnosis code, since this was a pre-op procedure. They thought, though, that the charge would be around $250.

At this point, David had to go meet an appointment, so I took over. I called Blue Cross Blue Shield, gave the information to the agent, and waited while she tried to figure out the answer. "We can't do pricing for hospitals," she told me at one point. Hospitals, it seems, have just too labyrinthine a discount policy for even the insurance agents to figure out. But bless her, she kept trying.

She needed a procedure code, however, which is different from a diagnostic code. After eight minutes of checking her own resources, she put me on hold and called the urgent care center herself. They referred her to the hospital's billing center, so the agent put me on hold again and called the hospital. (Say what you will about Blue Cross Blue Shield, they do have excellent customer service.) The hospital provided the necessary code, so the agent went off again to check.

Alas, she finally told me, this was indeed a hospital procedure, and therefore she would not be able to tell me what the cost would be. However, she thought it would be around $250, which means that our portion would be around $50.

Let me ask you something else, I said. Suppose David goes to a doctor and the EKG is done right there in the doctor's office. Would we then pay only the copay for a doctor's visit - $20 for a generalist, $40 for a specialist? The agent checked, and told me I was absolutely right. She sounded surprised.

She thanked me for my patience, and I thanked her for her excellent service (and indeed she was very accommodating). The phone call lasted 22 minutes, and I still was not sure what this procedure would cost.

Next I called a nearby medical group and asked if they are equipped to do EKGs right there in the office. Yes we are, said the receptionist. And, I pursued, if my husband sees a doctor who then immediately does an EKG, do we then just pay the copay? Yes indeed, she said.

So my husband has an appointment for tomorrow afternoon, and it's going to cost us $20 instead of $50 (more or less - we never did find out for sure), and it took only about an hour of our time to figure this out, plus of course whatever it cost Blue Cross, the hospital, the urgent care center, and the doctor's office who helped us.

In France, by contrast, charges are posted on the doctor's office wall for all to read.

Interestingly, the per-capita cost of health care in the U.S. is nearly double its cost in France. Personally, I think socialized medicine is a great way to keep costs down and increase efficiency. But if I were a total free-market type, I'd be equally disgusted with the U.S. system. How can consumers possibly influence the market if providers make it almost impossible to know costs?

To be perfectly honest, I read only one book that made it onto Publishers Weekly's and the New York Times's top ten lists, and I wasn't wild about it. Interestingly, those two lists agreed about only three titles. My list, which is even more fallible than theirs, is at least different : it doesn't include a single book they liked.The books on my list are not scholarly or even intellectual. My favorite novels (this year and every year) are books that tell stories, that let me peek into other people's minds and hearts, and that are funny or at least upbeat enough not to leave me clinically depressed. The nonfiction books on my list either interested me in topics I knew little about or deepened my understanding of topics that already interested me. They did this through excellent journalism, human interest stories, and just the right amount of authorial involvement with the topic.

Eight of these books were first published in 2010. The other two were published in the U.S. in 2009 and came out in paperback this year. I've reviewed or commented on all of them on this blog or elsewhere. To read my review, click on the pound sign. To see what Amazon has to say about a book, click on its title.

Wednesday, December 22, 2010

When my friend Irene, who reads much more deeply than I do, said "I love this book," I thought, Uh oh. Now I'm going to feel shallow unless I read it too. So I put a hold on it at the public library (no commitment required), and I looked at Amazon's reviews, which you can find here.

Whoa... an "enthralling narrative"? "Luminous"? "Absorbing and delightful"? "Lively and lucid"? Improbable descriptors for a book about two middle-aged female linguists who discover a Syriac palimpsest in St. Catherine's Monastery, and I've been in publishing long enough not to trust book-jacket blurbs.

Still, it's no mean feat to garner favorable reviews - or, really, any reviews at all - from the New York Times, the Christian Science Monitor, the Washington Post, Books and Culture ... well, I was beginning to be embarrassed that I hadn't heard of the book before my friend tipped me off. And now that I've read it, I pass her tip on to you.Janet Soskice, who is Professor in Philosophical Theology at the University of Cambridge, has nevertheless written a fascinating biography of Agnes Lewis and Margaret Gibson, twin sisters from Scotland who were never as famous as they deserved to be for discovering an ancient biblical manuscript.

Their discovery, which came at a time when ancient biblical manuscripts were all the rage, was of one of the oldest New Testament manuscripts ever found. It contained most of the Gospels, almost definitively proved that the original book of Mark did not include the snake-handling, poison-drinking verses in the last chapter, and was written in Syriac - first cousin to the Aramaic spoken by Jesus and the disciples. So why have we never heard of Mrs. Lewis and Mrs. Gibson?

Mostly because they were women. Born in 1843, they educated each other, becoming proficient in a variety of languages ancient and modern. They could not earn university degrees, because universities in mid-nineteenth century did not award degrees to women. Besides, they were Scottish Presbyterians, who were not especially in favor at Oxford or Cambridge. And several university professors desperately wanted the credit for their work.

Soskice has done a fine job of presenting them and their era in all their glorious eccentricities, turning their story into a good read even for people who are not usually fascinated by archaeological findings and ancient manuscripts.

Thursday, December 16, 2010

Last week a federal judge from Virginia ruled that part of The Patient Protection and Affordable Care Act is unconstitutional, and now the legal battle is moving to Florida. Also last week a Bloomberg poll found that 55% of Americans would like to repeal the health-care law, while only 40% want to keep it as is (5% aren't sure).

Now, I'm not sure what all of those 55% were thinking. I can imagine wanting to repeal the Affordable Care Act if I were fully persuaded that a better health-care law would immediately replace it - one that was funded either by a single payer or by not-for-profit private insurance; one that would put price controls on pharmaceuticals, medical equipment, hospitals, medical salaries, and other out-of-control expenses; one that would dramatically lower the cost of medical education so that we'd have more doctors, and so that more of them could afford to go into primary care; one that would assign a lot of primary care to pharmacists, midwives, physician assistants ...

Yes, I like socialized medicine. Not every aspect of it, and not necessarily the way it is practiced in every country that has it (though I'd be quite happy with France or Switzerland pretty much across the board). But even so, I don't think I would have answered yes to repealing the health-care law, because I don't think America has yet figured out how to do health care better.

Alas, most Americans are completely unaware that health care as practiced in other developed countries costs considerably less than our patchwork system, and that the results are nearly always equivalent or better. In fact, an October 2010 study by the Commonwealth Fund shows that "even as health care spending per capita has increased in the U.S. over the last three decades, the nation has fallen behind 12 other wealthy nations in 15-year survival for men and women at ages 45 and 65." Furthermore, the study points out, these rates can't be explained by smoking (we smoke less) or obesity (we're obese, but our obesity rate has increased less).

Steven Miles, MD, Professor of Medicine and Bioethics at the University of Minnesota Medical School in Minneapolis, has put together a fascinating Power Point presentation comparing health care in 15 developed nations. To see it, go to his faculty web page, scroll down (reading his impressive credentials as you go), and click on "US and Developed Countries: Comparing Health Care Systems - 2009." In 48 slides he not only compares systems, he also dispels myths and offers alternatives. Here are a few of his findings:

Of the 15 countries surveyed, the U.S. spends the most per capita on health care.

The U.S. has the highest infant mortality and the lowest female life expectancy at birth.

The U.S. has the highest rates of preventable death.

The U.S. has the lowest number of MDs per capita.

Hospital stays are shortest in the U.S.

Heart patients are likely to get more high-tech treatment in the U.S., but survival rates are the same as in countries that rely primarily on meds.

Hip replacements are done more quickly in the U.S., but the fewest number of people get them.

Americans should be healthier than others: we smoke and drink less than most, and we are on average younger than the others. We are more obese, however.

The U.S. government - before the Affordable Care Act - was already spending more per capita on health care than were the governments of most of the other developed nations. U.S. individuals were spending way more.

A major reason that Americans spend more, with poorer results, is that (unlike people in other countries) we do not make adequate use of primary care. A minority of us have a primary care provider that we see regularly. Too many of us neglect maintenance and go straight to specialists when the machine breaks down.

In spite of all this depressing (for Americans) data, Dr. Miles is an optimist: he thinks the U.S. will eventually wake up and improve health care for political and economic reasons. "The US cost of health care is so high that it is hampering our ability to sell products overseas," he told me. "Consider that about 10% of a $40,000 car made in Sweden is the built-in cost of its health-care system. For a similar US car, the health-care component is $6,800. Who will pay $2800 for an invisible car accessory?"

Probably someone who thinks that socialized medicine is diabolical, and that American health care is the best in the world.

Tuesday, December 14, 2010

Was I born on the wrong continent? Well, if you're talking bread, I'll definitely opt for the baguette. But Geoghegan (rhymes with "Reagan") says little about food, alas, in this comparison between American and Western European - mostly German - lifestyles. Instead, he looks at work, leisure, taxes, benefits, labor, management, social policy...

Don't let your eyes glaze over just yet. Geoghegan is a delightfully quirky writer who manages to convey a lot of information while making you think you're reading a chatty and often humorous travel book. Indeed, travel writing inspires him:

For years I read the front page [of the New York Times] about European unemployment, the collapse of social democracy, etc. But then I'd flip to the travel page and get the real news, the news that they don't dare put on page one, that every year in Europe, the whole place keeps getting nicer.

Geoghegan, a Chicago labor lawyer, made several extended trips to France, Switzerland, and Germany to study European socialism. He gives his conclusion in the preface:

The cover of the February 16, 2009, Newsweek announced: "WE ARE ALL SOCIALISTS NOW." The argument is that U.S. government spending is nearly as high as Europe's. A decade ago, the U.S. government was spending 34.3 percent of GDP, compared with 48.2 percent in the "euro-zone," which is Europe without the UK. Now, while the Continent is at 47 percent, we have gone up to 40.

And, in fact, I think the U.S. will close the gap. But in a sense, the more we spend, the less socialist we become. For whether it is health care or education, we use the private market to pay for the distribution of public goods. In other words, we pay socialist-type taxes so that the private insurance companies, drug companies, and, yes, doctors can profiteer.

That's the crisis of our time: we're paying for European-type socialism, without getting the equivalent payback.

Much of the rest of the book describes the European payback (and this will be counter-intuitive to a lot of American readers): Fewer poverty-stricken seniors and children. Six weeks' vacation time plus more paid holidays. Cheaper higher education, health care, day care, concerts. Paid maternity and paternity leave. Higher old-age pensions. Nursing-home benefits. Cleaner, faster, more readily available public transportation. More efficient land-use planning. Lower unemployment. More successful small businesses.

The only area in which the U.S. outshines its European counterparts is GDP - and Geoghegan offers fascinating observations as to why that actually may be making American lives more frantic and yes, even more expensive than the lives of European socialists.

Ironically, some of the structures that make German socialism work were developed by Americans during the occupation after World War II. Rather than the authoritarian, top-down socialism of the Nazis, the occupiers insisted on a bottom-up socialism where the workers themselves would have a big influence in organizational management. As a result, German businesses are much more democratically run than American businesses, who never adopted the practices themselves.

And some of the German bureaucratic regulation that Americans love to mock, says Geoghegan, has enabled Germany to become a major exporter of durable goods - really durable ones like Mercedes and BMWs - even as the U.S. has been ramping up its trade deficit. In fact, while the U.S. is increasing its debt by $1 trillion a year, Germany has no net external debt - and in fact vies with China for first place in world exports, an amazing feat for a country that has 82 million people compared with China's 1.3 billion. And yet "Americans still seem unaware that it's not just East Asia but the socialist Europeans who have outcompeted us in global markets as we sink deeper into debt."

So was Geoghegan born on the wrong continent? I don't think so. Like T.R. Reid, author of The Healing of America (a wonderfully enlightening book comparing health-care systems in various developed nations), Geoghehan wants us Americans to stop thinking we're best at everything, to start paying attention to how other countries handle vexing problems similar to our own, and to adapt their best solutions to our situation in ways that will give us happier, healthier lives. Our house is on fire, there's a fire station across the street, yet we're trying to fight the fire with buckets of water - or oil. "I know on the right and even in the center I am dismissed as a European-style liberal," he writes. "But my question for those on the right is as follows: do they care about the sovereignty of our country? Then they better start taking seriously what the Europeans do."

Monday, December 13, 2010

Several of my conservative Facebook friends responded to yesterday's post about Social Security. I commented that "my dad, who was born in 1910, used to thank God every day for Social Security. Beforehand, he said, Grandpa too often lived in a tiny unheated room in the attic."

One of my friends responded, "LaVonne, I would be willing to bet money that your father would have done fine had he been allowed to keep what is taxed away in Social Security. What would he have been able to do had his lifetime income been 15-20% higher?"

My first response is historical: his income would not have been 15-20% higher, because payroll taxes gradually increased between 1937, when the first taxes were levied, until 1975, when he retired. Combining his tax and his employer's, he actually paid at a rate of between 1% and 5.85% (you can check the table here). If my dad had had that extra money, I'm sure he would have saved it - but it would not have financed his retirement.

My second response is practical. Yes, Facebook friend, at today's rates a person could take that extra 15% a year and finance his or her own Social Security. That is, if the person never was overwhelmed by huge educational loans, never lost his or her job, never lost a wage-earning spouse, never decided to use the extra money for the kids' college education or to pay down a mortgage or for catastrophic illness, never was disabled, and never ever spent the money on a vacation.

But now back to the real world.

Look at what's happening with 401(k)s. The theory behind 401(k)s, like my Facebook friend's theory about Social Security, was that individuals could save for their retirement more efficiently than their employers could. Maybe they could, but very few do. As I pointed out in my previous post, the average 50-something American has saved $29,000. If that person needs $50,000/year (before taxes and medical insurance) to live on during retirement, that person is going to need to have a savings account of $1.25 million dollars, or - if he or she gets the average Social Security benefit of $1164/month - a mere $900,800. According to this nifty goal calculator that takes varying interest rates, inflation, and personal parameters into account, our average wage-earner would need to save $1101.22/month for 40 years in order to save up that $1.25 million. And yes, it could be done - by perfect people in a perfect world.

My third response is moral. My dad would have provided for himself, and probably could have, since he was never jobless, had work with good benefits, was never widowed, and was retired for only 20 years, dying just before a debilitating illness completely exhausted his resources. But my dad wasn't thinking only about himself. He was thinking about his responsibility, as a Christian and as a citizen, to the people that used to be called "the less fortunate." He did not want public social programs cut - even if he would benefit by not having to pay taxes to support them - because he believed they were necessary for the common good.

Is Social Security the best way to assure the well-being of widows, orphans, the disabled, and the elderly? So far, it's the best we've got. No doubt it could be improved. There may be other, better ways to achieve the same goals: if our politicians were all working to serve the common good, their policy debates would serve to strengthen our programs. Sadly, the loudest voices in the land are preaching individual liberty without community concern, or community concern without individual sacrifice, or sacrifice for future generations but not for us.

1. The proposed reduction isn't a mere 2%, even though the amount removed from our paychecks will drop from 6.2% to 4.2%. I won't bore you with the math, but work it out (remembering that your employer will continue to pay 6.2%) or take it on faith - it's actually a 16.4% reduction.

2. Even though Congress says it will make up the difference from general operating funds, may I point out that Congress is also saying it will balance the budget? Bear in mind that Social Security is not currently part of the federal budget, but if general funds are used to keep it solvent, it will become a hostage of Congressional budget negotiations. Is that a good idea?

3. Once taxes are lowered - even if unwisely, and even if the results are devastating - it is almost impossible to raise them again. Hey, isn't that why the President and Congress are working on a tax cut agreement right now? Do we really think that people who plan to run for office in 2012 are going to suggest raising payroll taxes back to 6.2% at the end of 2011?

4. We need the Social Security safety net. If we damage it now, do we have alternate plans for taking care of seniors? Are we still thinking about privatizing Social Security the way we privatized pension plans? Now that was a big success, wasn't it! Did you know that a yearly retirement income of $36,000 requires investments of about $900,000? And that the average American in his or her 50s has saved ... (drumroll) ... $29,000?

An AARP poll last August found that the vast majority of Americans of all ages want Social Security to continue as a guaranteed benefit. Few younger people, however, think it will be there when they need it. If the payroll reduction makes it through Congress this year, Social Security's chance of survival grows still dimmer.

Folks, if we want the goods, we're going to have to pay for them. We can't keep on lowering all our sources of revenue while raising all our expectations of benefits, though a Bloomberg poll released this week shows that that's exactly what most of us want to do. And that's exactly what our politicians keep promising they'll do, even though it's impossible, and even though their efforts are already devastating our economy.

Yesterday Senate Budget Committee Chairman Kent Conrad (D-ND), referring to the Bloomberg poll, said that there's only one way for our elected officials to get us out of the mess we're in:

They have to be prepared to sacrifice their political careers to do what must be done for the nation. Look, if we fail to get our deficits and debt under control, America will become a second-class nation. We are going to slip over the abyss into a fiscal crisis that is as sure as we sit here.

How many of our 535 voting members of Congress have enough integrity to insist that we need to keep Social Security strong and that we will pay to do so - even if this means raising taxes?

Friday, December 3, 2010

A life dedicated to God's creation is a life dedicated to loving one's neighbor.

--Megan Anna Neff

Anyone who still thinks evangelicals are anti-environmentalists should read this book. So should evangelicals and other Christians who know that our overburdened earth needs all the help it can get - but who have no idea where to begin.

Lisa Graham McMinn is a professor of sociology, the author of several books, and a backyard raiser of chickens. Her daughter Megan Anna Neff (no relation to me) has an M.Div. from Princeton, has lived in Africa, and works as a doula. Their new (August 2010) book, Walking Gently on the Earth, is as docile as its title - often personal, usually self-effacing, sometimes lyrical. The authors do not claim to be experts or perfect practitioners of sustainable living, but they refuse to shut their eyes to reality.

McMinn and Neff base their environmentalism on a theology of abundance. Creation is good. It is as important in God's plan as redemption. When we care for the earth, we care for one another.By contrast, when we hurt the earth - its plants, its animals, its water and air - we hurt one another and our Creator God. And when we refuse to pay attention to what's happening all around us, we become like the bureaucrats in the Harry Potter series. The evil Lord Voldemort has returned, but

the Ministry of Magic thinks announcing the news would cast unnecessary fear into people and require a rather drastic change of focus, altering life as they were comfortably living it.

The Ministers choose to ignore the facts and attack the truth-tellers. Harry Potter knows this can't turn out well.

In just over 200 pages of text, of course, they can't treat any topic in depth. People already familiar with today's environmental issues won't find any new information here, though they may appreciate the authors' pervasive theological theme. On the other hand, people who aren't already environmentally oriented could be overwhelmed. Too much information! Too much to worry about!

Except that Lord Voldemort really is on the move, and hiding from him will not make him go away. The ecological crisis has already begun (see my review of Bill McKibben's Eaarth in the November issue of Christianity Today or online). As individuals, we can't do much to stop it - but together we can make a huge difference in the world. And together is the best way to read Walking Gently on the Earth.

This is a book for classrooms (though it is by no means academic and would need to be supplemented if used as a college text), or for church adult education programs, or for Christian book groups. It is not at its best when read at one sitting. If an hour is all you've got, read McMinn's excellent article in the fall/winter Conversations journal, "Food for the Soul," instead.

If possible, though, join with others to read and discuss this book one chapter at a time. Walking Gently on the Earth is a feast of information and ideas, and feasts should not be celebrated alone. Divide up the links provided at the end of each chapter and bring additional information back to the group. Brainstorm ways to begin practicing the kinds of creation care McMinn and Neff recommend. Together, celebrate God's bounty as you learn to care for the earth's needs.